Favorable Neurological Outcome Research Articles

Abstract 138: Epinephrine Before Defibrillation In Adults With Shockable Rhythm Out-of-hospital Cardiac Arrest

Introduction: Guidelines recommend epinephrine treatment after the first defibrillation in the resuscitation of patients with shockable rhythm cardiac arrest. Degrees to which routine practice adheres to clinical guidelines can be variable. Hypothesis: Epinephrine was administered prior to defibrillation in a non-trivial proportion of patients with shockable rhythm out-of-hospital cardiac arrest (OHCA). Such practice is associated with worse outcomes. Methods: We conducted a retrospective study in a North American OHCA epidemiologic registry between 2011 and 2015. We assessed the proportion of participants with shockable rhythm OHCA who received pre-defibrillation epinephrine and described their characteristics. In a propensity-matched cohort, we used logistic regression to evaluate associations between pre-defibrillation epinephrine and outcomes, i.e., pre-hospital return of spontaneous circulation (ROSC), survival to hospital discharge, and favorable neurological outcome (modified Rankin Scale score ≤3) at discharge. Results: Of 6938 individuals with shockable rhythm OHCA, 522 (7.5%) received epinephrine before defibrillation. Comparing these patients to those who did not receive pre-defibrillation epinephrine, mean time from emergency medical services activation to first defibrillation was longer (17.5 vs 10.5 min) and a greater proportion received epinephrine intra-osseously (24 vs 20%). In total, 392 (75%) and 5119 (80%) gained prehospital ROSC, 78 (15%) and 1237 (19%) survived to hospital discharge, and 48 (9%) and 996 (16%) had favorable functional outcome at discharge respectively. In propensity-matched analysis, epinephrine use prior to defibrillation was associated with statistically insignificant increases in odds of prehospital ROSC (OR=1.20, 95%CI 0.89-1.61; p=0.23), survival (OR=1.46, 95%CI 0.98-2.17; p=0.06), and favorable neurological outcome at hospital discharge (OR=1.21, 95%CI 0.76-1.93; p=0.43). Conclusions: Data from a North American OHCA registry found that epinephrine can be administered prior to defibrillation in up to 7.5% of patients with shockable rhythm cardiac arrest. Such approach was not associated with worse outcomes in propensity-matched analysis.

Abstract 325: Evaluation Of The 2015 Cardiopulmonary Resuscitation Guidelines For Patients With Nonshockable Out-of-hospital Cardiac Arrest; Results From The All-japan Utstein Registry 2022

Background: In nonshockable cardiac arrest (CA) patients, the 2020 cardiopulmonary resuscitation (CPR) guidelines have stressed that high-quality CPR improves survival from CA, as with the 2015 CPR guidelines. However, it is unknown whether the 2015 guidelines contributed to the favorable neurological outcomes in adult CA patients. The present study aimed to clarify the effects of the 2015 guidelines on adult CA patients using the data of the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of out-of-hospital CA (OHCA). Methods: From the data of this registry, between 2011 and 2020, we included adult witnessed OHCA patients due to cardiac etiology who had non-shockable rhythm as an initial rhythm. We excluded patients who received prehospital care in 2011, 2015, 2016, and 2020 because it was difficult to distinguish prehospital care based on either 2010 CPR guidelines, 2015, or 2020. We also excluded patients who received bystander CPR by citizens because we cannot assess the quality of bystander CPR. Study patients were divided into two groups based on the different CPR guidelines; the era of the 2010 guidelines (2010G) and the era of the 2015 guidelines (2015G). The endpoint was the favorable neurological outcome at 30 days after OHCA. Potential confounding factors based on biological plausibility and previous studies were included in the multivariable logistic regression analysis. These variables included the age, sex (male, female), advanced airway or not, the administration of adrenaline or not, the administration of saline or not, and time interval from call EMS to the scene. Results: Of the 1,259,960 patients registered in the All-Japan Utstein Registry, the data of 54,219 patients were included in this analysis. The 2015G was significantly higher in the 30-day favorable neurological outcome than the 2010G (2010G vs. 2015G = 1.5% vs. 1.8%: p=0.008). In the multivariate analysis, the adjusted odds ratio for 30-day favorable neurological outcome in OHCA patients in the 2015G compared to in the 2010G was 1.37 (95%CI 1.19-1.58, p<0.001). Conclusion: In the OHCA patients with non-shockable rhythm, the 2015 CPR guidelines were superior to the 2010 guidelines in terms of neurological benefits.

Abstract 15047: Survival With Favorable Neurological Outcome and Quality of CPR Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared to Non-Cardiac Disease

Introduction: Children with cardiac disease have higher rates of in hospital cardiac arrest (IHCA) compared to non-cardiac disease. We aimed to determine differences in survival in children with medical and surgical cardiac compared to non-cardiac disease following IHCA and to assess whether CPR quality was different between groups. Hypothesis: We hypothesized: 1) medical cardiac have worse and surgical cardiac have improved outcomes compared to non-cardiac patients, and 2) CPR quality is similar between groups. Methods: A secondary analysis of the ICU-RESUS citation project ( ICU-RESUS ; NCT02837497) was conducted. The primary outcome was survival to hospital discharge with favorable neurological outcome defined as a Pediatric Cerebral Performance Category score of 1 - 3 or no change from baseline. Secondary outcomes included physiologic measures of intra-arrest quality. Results: Of 1100 children with IHCA, 273 (25%) were medical cardiac, 383 (35%) were surgical cardiac, and 444 (40%) were non-cardiac. The medical cardiac group was less likely to survive with favorable outcome compared to the non-cardiac group (48% vs. 55%, aOR 0.59, CI 95 0.40, 0.88). There was no difference in outcome between the surgical cardiac (58%) and non-cardiac group. There were no differences in chest compression (CC) rate, CC fraction, ventilation rate, intra-arrest average target diastolic blood pressure or average target systolic blood pressure between medical cardiac vs. non-cardiac and surgical cardiac vs. non-cardiac groups. The surgical cardiac group was less likely to achieve target CC depth compared to non-cardiac group (OR 0.15, CI 95 0.02, 0.52). There was no difference in CC depth in medical cardiac vs. non-cardiac groups. Conclusions: In this large study of pediatric IHCA, medical cardiac patients had lower survival with favorable neurologic outcome compared to non-cardiac patients. Surgical cardiac patients had similar outcome to non-cardiac patients. CPR quality was similar in medical-cardiac and non-cardiac patients, however delivered CC depths were lower in surgical cardiac compared to non-cardiac patients.

Abstract 9689: Impact of Epinephrine Administration Route on the Outcomes of Cardiac Resuscitation of Acute Myocardial Infarction Patients With Cardiac Arrest in the Cardiac Catheterization Laboratory (iCPR Study)

Objectives: To compare the efficacy peripheral intravenous (IV), central IV, and intracoronary (IC) administration of epinephrine in acute myocardial infarction (AMI) patients with cardiac arrest in the cath lab. Methods: Prospective, two-center cohort pilot study of AMI patients with cardiac arrest in the cath lab. Patients who received mechanical circulatory support, primary fibrinolysis, anti-arrhythmic/vasopressors prior to cardiac arrest, or those with prior CAD or a cardiac arrest that lasted < 60 seconds were excluded. Outcomes included return of spontaneous circulation (ROSC), stent thrombosis, and survival-to-discharge with a favorable neurological outcome. Results: 158 patients were enrolled (Table 1). After adjusting for age and initial cardiac rhythm, the peripheral IV route had 5.5-fold lower odds (OR: 0.18, 95% CI: 0.07-0.49, p = 0.0007) of achieving ROSC compared with the central IV route, while the IC route had a similar odds compared to the central IV route ( p = 0.9516). Among those who achieved ROSC, the IC route had a higher odds for stent thrombosis compared to the central IV route (OR: 5.7, 95% CI: 1.9-17.2, p = 0.0022), but not the peripheral IV route ( p = 0.1277). The adjusted odds of achieving survival-to-discharge with a favorable neurological outcome were higher in the IC route compared to the peripheral IV route (OR: 7.8, 95% CI: 2.2 – 27.0, p = 0.0013), and similar in the IC and central IV routes ( p = 0.0585) (Table 2). Conclusions: Epinephrine administration via central IV has a higher odds achieving ROSC than via peripheral IV and a lower odds of stent thrombosis than via the IC route in patients with AMI who suffer from cardiac arrest during PCI.

Abstract 271: The Time Dependence Of The Effect Of Extracorporeal Cpr For Out-of-hospital Cardiac Arrest Patients

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) has been considered as a rescue therapy for refractory cardiac arrest patients. However, little is known about who is refractory to conventional CPR and when to judge the initiation of ECPR. Method: We performed a secondary analysis of the nationwide hospital-based prospective observational study (The JAAM-OHCA registry) in Japan. This study included adult OHCA patients aged ≥18 years who had an initial shockable rhythm between June, 2014 and December, 2019. We classified the included patients into the ECPR group or the conventional CPR group based on whether to receive ECPR or not. Low flow duration (LFD) was defined as the time from call to the initiation of ECPR or to the time of return of spontaneous circulation or termination of resuscitation. The primary outcome was 1-month survival with favorable neurological outcomes defined by cerebral performance category 1 or 2. We visually described the nonlinear relationship between LFD and the predictive probability of favorable neurological outcome using a restricted cubic spline by each group. Results: Of 57,754 patients registered in the JAAM-OHCA registry, 3807 patients were included in analyses (ECPR group, n = 865 and Conventional CPR group, n = 2942). In both groups, shorter LFD was associated with favorable neurological outcome. For first 30 minutes, the overall proportion of favorable neurological was higher in the Conventional CPR group, but due to the rapid decrease in Conventional CPR, it dropped down to almost the same probability before 20 min as that of shortest LFD around 25 min in the ECPR group. After that, the probability of favorable neurological outcome was constantly higher in the ECPR group. Conclusion: The judgement of refractory cardiac arrests and decision for ECPR should be delivered before 20 min from call to maximize the probability of favorable neurological outcome for those with an initial shockable rhythm.

Abstract 180: Impact Of Hot Debriefing Programs On Pediatric Cardiopulmonary Resuscitation Quality And Outcomes

Introduction: Successful cardiopulmonary resuscitation (CPR) outcomes rely on AHA guideline compliant chest compressions (CC). Resuscitation teams struggle to achieve these CPR metrics. Cold debriefing has led to higher quality CPR and improved patient outcomes. The impact of hot debriefing (HD) on CPR quality and patient outcomes is unknown. We sought to evaluate the association of HD on CPR quality and patient outcomes. Methods: Retrospective cohort of in-hospital cardiac arrests (IHCA), 0 to 18yo with complete quantitative CC metrics in the pediRES-Q database (1/2018 - 3/2021). We investigated exposure to HD, defined as hospital HD rate >50% in the 12 months prior to the CPR event, with AHA compliant CPR (CC fraction (CCF) ≥0.80, CC rate (CCR) 100-120/min, and CC depth (CCD) <1yo ≥3.4 cm, 1-8yo ≥4.4 cm, >8yo 4.5≥6.6 cm). HD vs. non-HD events by CPR quality were compared via Chi-square or Wilcoxon rank sum tests and stratified by age. For index events, we evaluated return of circulation (ROC), survival to hospital discharge (SHD) and favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1, 2, or no change from baseline). Multivariable logistic regressions with a Generalized Estimating Equation method, adjusted for age group, arrest duration, initial rhythm, illness category, and site clustering. Results: We evaluated 515 IHCA events stratified by HD exposure (221 w and 294 wo) and age. Across age ranges, there was no difference in CCD or CCF between groups. Median CCR was lower in HD exposure groups: <1yo, 110 vs 117 (p <0.001), 1-8yo, 110 vs 117 (p <0.001) and 8-<18yo, 110 vs 115 (p =0.003). There was no difference in compliance with a composite of CCF + CCR + CCD. The composite CCR + CCF had increased compliance in the HD exposure groups: <1yo, 37% (34 of 92) vs 21% (21 of 102) (p = 0.02), 1-8yo, 38% (27 of 72) vs 23% (26 of 111) (p = 0.05) and 8-<18yo, 42% (24 of 57) vs 25% (20 of 81) (p = 0.04). To assess patient outcomes, we evaluated 917 index arrests (255 w HD exposure and 662 wo). On multivariable analysis, no significant difference was found for ROC, SHD or favorable neurologic outcome by HD exposure. Conclusion: Pediatric IHCA events with HD exposure demonstrated improved CPR metrics for CCR and CCF. No association was identified for patient level outcomes.

Abstract 281: External Validation Of The Tips65 Score For Predicting Good Neurological Outcome In Out-of-hospital Cardiac Arrest Patients Treated With Extracorporeal Cardiopulmonary Resuscitation

Introduction: Estimating prognosis after out-of-hospital cardiac arrest (OHCA) at early timing during resuscitation efforts is important to select appropriate candidates for extracorporeal cardiopulmonary resuscitation (ECPR). The TiPS65 scoring system is a prediction model that can be used for predicting favorable neurological outcome of adult OHCA patients treated with ECPR using the following four variables: time from call to hospital arrival, initial cardiac rhythm on hospital arrival, initial pH value, and age. However, it is not yet externally validated. We aimed to perform the external validation of the TiPS65 score. Methods: This prognostic study used data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a nationwide, multicenter, prospectively registered database including 83 emergency departments in Japan from January 2018 to December 2019. All adult OHCA patients with shockable rhythm who were treated with ECPR were included. The primary outcome was 30-day survival with favorable neurological outcome defined as Cerebral Performance Category 1 or 2. The predicted probability of outcomes in this cohort was calculated according to the formula developed in the original study. The discrimination and calibration performances were investigated with c-statistic and calibration plots, respectively. Results: A total of 590 patients (men: 517 [81.6%], median age [interquartile range]: 60 [50-69] years) were included, and favorable neurological outcome were reported in 64 (10.8%). The c-statistic of the prediction model was 0.752 (95% CI: 0.694-0.81). The mean predicted probabilities were 1.6% (range: 1.6%-1.6%), 4.5% (3.1%-5.9%), 12% (10.1%-13.9%), 26.2% (22.7%-29.7%), and 48.8% (48.8%-48.8%) for a TiPS65 score of 0, 1, 2, 3, and 4, respectively. These scores were generally well-calibrated to the observed outcomes. Conclusions: In our external validation study of the TiPS65 score for OHCA patients treated with ECPR, the score showed good discrimination and calibration performances. This score would be helpful in the decision-making process for patient selection for ECPR after OHCA.

Abstract 275: The First Series Of Hypothermic Out-of-hospital Cardiac Arrests In A Temperate Urban Area Resuscitated With Prehospital Or Inhospital Extracorporeal Cardiopulmonary Resuscitation: A Fifteen-year Observationnal Study

Introduction: Accidental hypothermia designates an unpredicted drop in body temperature below 35°C. The risk of ventricular fibrillation is major below 28°C and cardiac arrest is almost certain below 24°C. In such cases, conventional cardiopulmonary resuscitation is often inefficient. Hypothesis: Hypothermic out-of-hospital cardiac arrest (OHCA) occurs even in temperate urban areas and extracorporeal cardiopulmonary resuscitation (ECPR) has shown good outcomes with this indication. Methods: We conducted a retrospective observational study of patients admitted to a university hospital in Paris, France. We reviewed patients consecutively admitted between January 1, 2008 and April 31, 2022 and treated with prehospital or inhospital ECPR following refractory hypothermic OHCA. The primary outcome was survival at 28 days with good neurological outcomes, defined as Cerebral Performance Category (CPC) 1 or 2. We compared patients according to their cold air or cold water exposure. Results: A total of 38 patients were analysed. Patient characteristics and outcomes are detailed in Table 1. A total of 15 patients (40%) survived at 28 days, 13 (34%) of whom with good neurological outcomes despite a median low-flow of 85 min. No patient survived with good neurological outcomes in the cold-water group. Conclusion: Survival rates with favourable neurological outcomes at 28 days stood at 34% of all patients with hypothermic OHCA who were resuscitated with ECPR. Prehospital ECPR tended to show better survival results (39% vs 30%) but further data are needed to confirm this as the difference was not statistically significant. We found no survivors in the cold-water group raising the question of ECPR indication for these patients in temperate urban areas. In any case, temperature measurement should be systematic in OHCA and there should be predefined care pathways including ECPR for hypothermic OHCA patients even in urban settings with a temperate climate.

Abstract 214: A Counterfactual Machine Learning Model Study To Estimate The Impact Of Coronary Angiography For Out Of Hospital Cardiac Arrest

Background: The American Heart Association guidelines for resuscitation 2020 recommends emergency coronary angiography (CAG) in cases of out-of-hospital cardiac arrest (OHCA) after return of spontaneous circulation (ROSC) with ST-segment elevation(STE) and, it is unclear how much CAG actually contributes to improved outcomes in various OHCA patient populations. The aim of this study is to estimate the impact of CAG on OHCA using a counterfactual machine learning model. Methods: We analyzed adult non-traumatic OHCA patients (43,977 cases) from June 2014 to December 2019 from the JAAM (Japan Association for Acute Medicine)-OHCA registry, which includes post-hospitalization data from 140 Japanese hospitals. We defined outcomes as favorable neurological outcomes (Cerebral Performance Categories (CPC) 1-2) and survival at 30 and 90 days. We estimated the outcome assuming that all patients had received CAG using a machine learning and counterfactual hypothetical model, and also estimated the outcome assuming that all patients had not received CAG. An average of each individual difference between the two estimations was calculated as average treatment effect (ATE) (%), which represents the effect of CAG on improving outcomes for the population. In addition, subgroup analysis was performed based on ROSC, STE and initial documented rhythm. Results: The ATE(%, 95% confidence interval) of CAG in all OHCA patients for CPC 1-2 at 30 and 90 days was 3.11% (2.92-3.30) and 1.85% (1.74-1.95), and survival at 30 and 90 days was 6.25%(5.93-6.57) and 2.20%(1.88-2.52), respectively. The subgroup analysis of ATE for CPC 1-2 at 90 days was particularly lower in the no STE group, initial pulseless electrical activity (PEA) group and initial asystole group than in the STE group and initial ventricular fibrillation(VF) group (Figure). Conclusions: In the JAAM-OHCA registry, we used a counterfactual machine learning model to estimate the effect of CAG on OHCA.

Abstract 137: Effect Of Chest Compression Release Velocity On Cerebral Perfusion Pressure In A Porcine Experimental Model Of Cardiac Arrest.

Background: Previous studies have shown that chest compression release velocity (CCRV) of over 400mm/s is associated with improved survival and favorable neurologic outcome after cardiac arrest. However, it is uncertain whether CCRV during CPR is related to cerebral perfusion pressure (CePP). The purpose of this study was to evaluate the association between CCRV and CePP in a porcine cardiac arrest model. Methods: After 6 minutes of untreated ventricular fibrillation, 2 cycles of basic life support (BLS) and 12 cycles of advanced cardiovascular life support (ACLS) were conducted. During ACLS phase, CCRV was accelerated from 250mm/s to 450mm/s by 50mm/s (accelerating group) or decelerated from 450mm/s to 250mm/s by 50mm/s (decelerating group). Both groups performed BLS with the self-set value of the mechanical CPR device (LUCAS 2 chest compression system, CCRV of 170mm/s). Twenty-four pigs were randomly assigned to each group. Macrovascular circulation (CePP) and microvascular circulation using laser doppler flowmetry presented as a fraction of the baseline flow (f-LDF) were measured. We excluded the last 2 cycles of ACLS phase from the analysis due to time-dependent deterioration effects of hemodynamic outcomes. Linear mixed model was used to measure the median difference in CePP and f-LDF according to CCRV. Results: A total of 24 pigs were analyzed. Decelerating group of CCRV of 400mm/s showed significantly higher CePP values compared to the group of 170mm/s. Effect of changes in CCRV on CePP, stratified by groups, are as follows (median, [95% confidence intervals]): 1. Accelerating group: CCRV of 170mm/s; reference, 250mm/s; -1.98 [-10.78 - 11.79] mmHg, 300mm/s; -1.88 [-11.15 - 12.55] mmHg, 350mm/s; -2.55 [-11.46 - 12.24], 400mm/s; -6.05 [-5.59 - 16.86], and 2. Decelerating group: CCRV of 170mm/s; reference, 250mm/s; 5.71 [-16.27 - 27.11] mmHg, 300mm/s; 6.01 [-16.28 - 27.90] mmHg, 350mm/s; 6.96 [6.36 - 47.70], 400mm/s; 26.96 [6.36 - 47.70]. However, there was no significant CCRV effects on f-LDF (Accelerating CCRV of 400mm/s; 1.54 [ -0.03 - 3.10] and decelerating CCRV of 400mm/s; -2 [-4.42 - 0.34]). Conclusion: In a VF cardiac arrest porcine study, CCRV of 400mm/s at early phase of CPR has positive effects on CePP.

Abstract 151: Effect Of Time From Collapse To Prehospital Return Of Spontaneous Circulation On Neurologically Favorable Survival In Patients With Out-of-hospital Cardiac Arrest At Nighttime Versus Daytime

Background: Survival with favorable neurological outcomes is one of the goals in patients with out-of-hospital cardiac arrest (OHCA). Although previous studies have shown that a chance of neurologically intact survival was significantly lower at nighttime than at daytime in patients with OHCA, details are uncertain. The aim of this study was to evaluate the effect of time from collapse to prehospital return of spontaneous circulation (ROSC) on neurologically favorable survival in patients with OHCA at nighttime versus daytime. Methods: Using a nationwide OHCA registry database from 2005 to 2020 in Japan, a cohort of 1,902,986 patients with OHCA were retrospectively screened. In the present study, a total of 128,180 patients with witnessed OHCA who achieved prehospital ROSC were included. Nighttime was defined as 6:00 pm through 5:59 am. Neurologically favorable survival was defined as cerebral performance category score of 1 or 2 at 1 month. Results: Patients with witnessed OHCA at nighttime were likely to be younger (70.3±16.0 vs. 72.7±15.3 years, p<0.001) and to have shorter time from collapse to resuscitation (8.1±7.3 vs. 8.6±7.2 min, p<0.001) than those at daytime (6:00 am to 5:59 pm), while time from collapse to ROSC was longer in patients with OHCA at nighttime (18.3±12.7 vs. 17.9±12.2 min, p<0.001). Overall, nighttime OHCA was associated with a lower rate of neurologically favorable survival at 1 months than daytime OHCA (30.9% vs. 31.8%, p<0.001). The negative effect of nighttime OHCA on neurologically favorable survival was observed especially when the time from collapse to prehospital ROSC was within the range of 5 to 10 minutes (Figure). Conclusions: Nighttime rather than daytime OHCA was associated with neurological impaired survival or death at 1 month. The negative effect of nighttime OHCA was pronounced when prehospital ROSC was achieved 5 to 10 minutes after collapse.

Abstract 258: Age, Sex And Survival Of Ventricular Fibrillation Out-of-Hospital Cardiac Arrest: The Influence Of Electrocardiogram Waveform Measures

Background: Studies of sex-based outcome in out-of-hospital cardiac arrest (OHCA) have produced mixed results that may depend on age. Menopause produces a range of effects that may influence resuscitation. We used quantitative measures of the presenting OHCA ventricular fibrillation (VF) waveform - a surrogate of the myocardium’s acute physiology - to assess whether outcome differences according to sex and age group may be mediated via a biologic mechanism. Methods: We conducted a retrospective cohort study of adults with non-traumatic VF-OHCA in a metropolitan Emergency Medical Services system between 2008-2020. We used multivariable logistic regression to assess the association of outcome (survival to hospital discharge, favorable neurological outcome (Cerebral Performance Category (CPC) 1 or 2), with sex and age group (<55, > 55 yrs). We then determined the proportion of the outcome difference mediated by the waveform measure by incorporating previously described quantitative VF waveform measures - an estimated probability of survival (P Survival ) and amplitude spectrum area (AMSA - into the model individually. Results: Of 1526 VF-OHCA patients, average age was 62 years, and 29% were female. Overall, younger women were more likely to survive than younger men (survival 67% vs 54%, p=0.02 with CPC 1-2 61% vs 51%, p=0.07), while older women and older men had similar worse outcomes. After adjusting for Utstein characteristics, women <55 compared to men <55 was associated with greater odds of survival to hospital discharge (OR 1.93, 95% CI 1.23-3.09, p=0.005) and CPC 1-2 survival (OR 1.72, 95% CI 1.10-2.71, p=0.02), whereas no associated sex-based differences in these outcomes were observed between the older groups. Each waveform measure mediated some of the beneficial association between sex and age group with survival: 47% for P Survival and 25% AMSA. Conclusions: Women <55 years were more likely to survive to hospital discharge and with favorable neurological status compared to men <55 years, a sex-associated outcome difference not observed in the older age group. The biologic mechanism represented by VF waveform measures mediated some (47% at most), though not all, of the outcome differences.

Long-Term Functional Outcome and Quality of Life After Surgical Evacuation of Spontaneous Supratentorial Intracerebral Hemorrhage: Results from a Swedish Nationwide Cohort

To investigate long-term survival, neurologic outcome, and quality of life in patients with spontaneous supratentorial intracerebral hemorrhage (ICH) treated with craniotomy and hematoma evacuation. A nationwide multicenter retrospective analysis of 341 patients who underwent craniotomy and evacuation of supratentorial ICH between January 1, 2011, and December 31, 2015, was performed. Baseline characteristics associated with 6-month mortality and long-term mortality were investigated. Survivors received a questionnaire about their state of health from which EuroQol 5D (EQ-5D) and modified Rankin scale (mRS) were obtained. Predictors of mortality, unfavorable outcome, and life quality were analyzed. The mean follow-up time was 55.2 months. Predictors of 6-month mortality in multiple regression analysis were age ≥75 years, previous myocardial infarction, lower level of consciousness, and mechanical ventilation. Predictors of long-term mortality were higher age and mechanical ventilation. At follow-up, 49.5% of survivors had a favorable neurologic outcome (mRS ≤3). Predictors of an unfavorable functional outcome were higher age and ICH volume ≥50 mL. The mean EQ-5D health index was 0.719, and the mean EQ-5D visual analog scale score was 53.9. In multiple regression, only a higher mRS score was significantly associated with worse life quality. Knowledge about survival, functional outcome, and life quality as well as their predictors in this specific patient group is previously primarily described in short-term follow-up. This multicenter study provides novel information in the long-term perspective, which is important for improved surgical decision-making and prognostication.

Abstract 178: Development And Validation Of The Utstein-based Machine Learning Algorithms To Predict Neurological Outcomes After Out-of-hospital Cardiac Arrest: A Retrospective Analysis Of The Pan-asian Registry

Introduction: The proportion of favorable neurologic outcome from the survival after Out-of-Hospital Cardiac Arrest (OHCA) remains poor, esp. in the Asian communities. By using the machine learning (ML) approach, we aimed to develop and validate the the Utstein-based ML algorithms to predict neurological outcomes after OHCA in this population. Methods: We conducted a retrospective analysis of data collected from the registry of Pan Asian Resuscitation Outcomes Study (PAROS) Network, an international and multi-center cohort study of OHCA across 13 countries in this region. All adult (≥ 18 years) EMS-treated OHCA patients between Jan 2009 to May 2018 in the registry were included, with variables followed the Utstein recommendations and conform to a unified taxonomy established by the network. The primary outcome was defined as good neurological outcome with cerebral performance category 1 or 2. Random splitting was used to divide the dataset into the training/validation and testing cohorts at around 2-to-1 ratio. Four supervised ML models, including Random Forest (RF), Gradient Boosting (GB), Extra Trees (ET), and CatBoost (CB) classifiers were employed to construct the prediction models, and performances were evaluated and compared with traditional logistic regression (LR) by the area under the receiver operating characteristic curve (AUC) in the testing cohort. Results: We included 194,300 records for analysis. Of them, 6,342 (3.3%) achieved good neurologic outcome. Among the constructed ML models, RF obtained the best AUC performance (0.924, 95% CI: 0.917-0.932), followed by ET (0.922, 95% CI: 0.915-0.930), CB (0.922, 95% CI: 0.915-0.930), and GB (0.910, 95% CI: 0.901-0.920). Although there was no difference in performance between each ML models, RF performed significantly better than using the traditional LR. The top important features were first arrest rhythm, age, witnessed by EMS, event location, and duration from call to EMS arrival. Conclusions: The ML approach showed excellent discriminatory performance to predict good neurologic outcome for EMS-treated OHCA patients in the Pan-Asian communities. It has the potential to save more life or provide termination-of-resuscitation if successfully implemented in the EMS system.

An epidemiological assessment of choking-induced out-of-hospital cardiac arrest: A post hoc analysis of the SOS-KANTO 2012 study

ObjectivesThe aim of this study was to reveal the neurological outcomes of choking-induced out-of-hospital cardiac arrest (OHCA) and evaluate the presence of witnesses, cardiopulmonary resuscitation (CPR) performed by a witness (bystander-witnessed CPR), and the proportion of patients with favourable neurological outcomes by the time from CPR by emergency medical services (EMS) to the return of spontaneous circulation (ROSC) (CPR-ROSC time). MethodsWe retrospectively analysed the SOS-KANTO 2012 database, which included data of 16,452 OHCAs in Japan. We selected choking-induced OHCA patients aged ≥ 20 years. We evaluated the neurological outcomes at 1 month with the Cerebral Performance Category (CPC). We defined favourable neurological outcomes (CPCs: 1–2) and present the outcomes with descriptive statistics. ResultsOf 1,045 choking-induced OHCA patients, 18 (1.7%) had a favourable neurological outcome. Of 1,045 OHCAs, 757 (72.6%) were witnessed, and 375 (36.0%) underwent bystander-witnessed CPR. Of the 18 OHCAs with favourable outcomes, 17 (94.4%) were witnessed, and 11 (61.1%) underwent bystander-witnessed CPR. With a CPR-ROSC time of 0–5 minutes, the proportion of patients with favourable neurological outcomes was 29.7%, ranging from 0% to 6% in the following time groups. ConclusionsThe neurological outcome of choking-induced OHCA was poor. The neurological outcomes deteriorated rapidly from 5 minutes after the initiation of CPR by EMS. The presence of witnesses and bystander-witnessed CPR may be factors that contribute to improved outcomes, but the effects were not remarkable. As another approach to reduce deaths due to choking, citizen education for the prevention of choking may be effective.

Comparative Effectiveness of Amiodarone and Lidocaine for the Treatment of In-Hospital Cardiac Arrest

American Heart Association Advanced Cardiac Life Support (ACLS) guidelines support the use of either amiodarone or lidocaine for cardiac arrest caused by ventricular tachycardia or ventricular fibrillation (VT/VF) based on studies of out-of-hospital cardiac arrest. Studies comparing amiodarone and lidocaine in adult populations with in-hospital VT/VF arrest are lacking. Does treatment with amiodarone vslidocaine therapy have differential associations with outcomes among adult patients with in-hospital cardiac arrest from VT/VF? This retrospective cohort study of adult patients receiving amiodarone or lidocaine for VT/VF in-hospital cardiac arrest refractory to CPR and defibrillation between January 1, 2000, and December 31, 2014, was conducted within American Heart Association Get With the Guidelines-Resuscitation participating hospitals. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were 24h survival, survival to hospital discharge, and favorable neurologic outcome. Among 14,630 patients with in-hospital VT/VF arrest, 68.7%(n= 10,058) were treated with amiodarone and 31.3%(n= 4,572) with lidocaine. When all covariates were statistically controlled, compared with amiodarone, lidocaine was associated with statistically significantly higher odds of the following: (1) ROSC (adjusted OR [aOR], 1.15, P= .01; average marginal effect [AME], 2.3; 95%CI, .5-4.2); (2) 24h survival (aOR, 1.16; P= .004; AME, 3.0; 95%CI, 0.9-5.1); (3) survival to discharge (aOR, 1.19; P< .001; AME, 3.3; 95%CI, 1.5-5.2); and (4) favorable neurologic outcome at hospital discharge (aOR, 1.18; P< .001; AME, 3.1; 95%CI, 1.3-4.9). Results using propensity score methods were similar to those from multivariable logistic regression analyses. Compared with amiodarone, lidocaine therapy among adult patients with in-hospital cardiac arrest from VT/VF was associated with statistically significantly higher rates of ROSC, 24h survival, survival to hospital discharge, and favorable neurologic outcome.

Public-access defibrillation and favorable neurological outcome after out-of-hospital cardiac arrest during the COVID-19 pandemic in Japan

BackgroundEarly public-access defibrillation (PAD) effectively improves the outcomes of out-of-hospital cardiac arrests (OHCA), but several strategies implemented to prevent the spread of coronavirus disease 2019 (COVID-19) could decrease the availability of PAD and worsen outcomes after OHCA. Previous studies have reported conflicting findings, and there is a paucity of nationwide observations. This study aims to investigate the impact of COVID-19 on PAD and OHCA outcomes using a nationwide OHCA registry in Japan, where PAD is well-documented.MethodsThis secondary analysis of the All-Japan Utstein Registry, a prospective population-based nationwide registry of OHCA patients, included patients aged ≥ 18 years with bystander-witnessed OHCA and an initial shockable rhythm who were transported to medical facilities between January 1, 2005, and December 31, 2020. The analytical parameters of this study were the proportion of patients who underwent PAD and patients with one-month survival with favorable neurological outcomes, defined as a cerebral performance category score of 1 or 2. We compared the data between 2019 and 2020 using a multivariable logistic regression analysis.ResultsDuring the study period, 1,930,273 OHCA patients were registered; of these, 78,302 were eligible for the analysis. Before the COVID-19 pandemic, the proportion of OHCA patients who underwent PAD and demonstrated favorable neurological outcomes increased gradually from 2005 to 2019 (P for trend < 0.001). The proportion of patient who had PAD were 17.7% (876/4959) in 2019 and 15.1% (735/4869) in 2020, respectively. The proportion of patient who displayed favorable neurological outcomes were 25.1% (1245/4959) in 2019 and 22.8% (1109/4869) in 2020, respectively. After adjusting for potential confounders, a significant reduction in the proportion of PAD was observed compared to that in 2019 (adjusted odds ratio [AOR], 0.86; 95% confidence interval [CI], 0.76–0.97), while no significant reduction was observed in favorable neurological outcomes (AOR, 0.97; 95% CI 0.87–1.07).ConclusionThe proportion of PAD clearly decreased in 2020, probably due to the COVID-19 pandemic in Japan. In contrast, no significant reduction was observed in favorable neurological outcomes.

The long-term surgical outcomes of low-grade epilepsy-associated neuroepithelial tumors.

This study aimed to evaluate the surgical outcomes and relevant prognostic factors in patients with low-grade epilepsy-associated neuroepithelial tumors (LEAT) and, especially, to develop a scoring system to predict postoperative seizure outcomes. The clinical data of patients who underwent epilepsy surgery for LEAT were retrospectively studied. The surgical outcomes of seizure and neurological statuses in patients were evaluated using Engel classification and modified Rankin Scale (mRS) scoring, respectively. A scoring system of seizure outcomes was constructed based on the weight of the β-coefficient estimate of each predictor in the final multivariate predicting model of seizure outcomes. Of the 287 patients (106 female) enrolled, the median age was 19 years at surgery and 10 years at seizure onset, with a median duration of epilepsy of 60months. Among 258 patients who were followed up for at least 12months, 215 (83.3%) patients had a favorable seizure outcome (Engel class I) after surgery, and 43 (16.7%) patients had an unfavorable seizure outcome; longer duration of epilepsy, discordant magnetoencephalography (MEG) findings, and acute postoperative seizures were significantly included in the scoring system to predict unfavorable seizure outcomes, and in the scoring system, accumulated scoring of 0-19 scores was recorded, which were finally grouped into three risk levels: low risk (risk < 30%), medium risk (30% ≤ risk < 70%), and high risk (risk ≥ 70%). In addition, favorable neurological outcomes (mRS score 0-1) were recorded in 187 (72.5%) patients, while unfavorable neurological outcomes were recorded in 71 (27.5%) patients, which were significantly related to poor seizure control, older age at surgery, and longer duration of epilepsy and hospitalization time. The long-term surgical outcomes of LEAT after surgery were satisfactory. A scoring system for predicting unfavorable seizure outcomes with different risk levels was developed, which could partly guide clinical treatments of LEAT.

Thoracic Spine Deformity Post Tetanus: A Case Report of Tetanus Post Circumcision

Tetanus is caused by clostridium tetani bacteria through skin breach. The tetanus is characterized by tonic contraction and muscle spasm which can cause vertebral fracture in some patients. we are reporting a young male patient who after ring circumcision technique had tetanus complicated into thoracic vertebral fracture with severe kyphotic deformity and lower limb functional impairment. The surgical management was performed in two stages: First stage consisted of Shwab 2 osteotomy, pedicle screws and rod fixation with good result for deformity correction. The second stage of surgery involved left transpedicular T6 and T5 corpectomies (Shwab 3 osteotomy) plus interbody titanium cage fixation which provided good spinal cord decompression. Tetanus is still a major complication of circumcision, tetanus complication may be devastating Early surgical deformity correction and spinal cord decompression provide favorable neurological and functional outcome for patients with spine deformity post tetanus. The Patient was able to walk with crutches 3 months post-surgery.

Fifteen-year secular changes in the care and outcomes of patients with out-of-hospital cardiac arrest in Japan: a nationwide, population-based study.

Countries have implemented initiatives to improve the outcomes of patients with out-of-hospital cardiac arrest (OHCA). However, secular changes in care and outcomes at the national level have not been extensively investigated. This study aimed to determine 15-year secular changes in the outcomes of such patients in Japan. Using population-based data of patients with OHCA, covering all populations in Japan (2005-19), patients for whom resuscitation was attempted were identified. The primary outcome was a favourable neurological outcome (Cerebral Performance Category 1 or 2: sufficient cerebral function for independent activities of daily life and work in a sheltered environment). Secular changes in outcomes were determined using a mixed-level multivariate logistic regression analysis. Overall, 1764440 patients (42.4% women; median age, 78 years) were examined. The incidence, median age, and proportion of patients who received bystander cardiopulmonary resuscitation (CPR) and dispatcher instructions for resuscitation increased significantly during the study period (P <0.001). A significant trend was noted toward improved outcomes over time (P for trend<0.001); favourable neurological outcome proportions 1 month after arrest increased from 1.7-3.0% (odds ratio, 1.03 per 1-incremental year). A remarkable increase was noted in favourable neurological outcomes in younger patients and patients with initial shockable cardiac rhythm, while improvement varied among prefectures. In Japan, collaborative efforts have yielded commendable achievements in the care and outcomes of patients with OHCA over 15 years through to 2019, while the improvement depended on patient characteristics. Further initiatives are needed to improve OHCA outcomes.